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[Injuries of the cervical spine in children]
Insights
Pediatric spine injuries are rare but often affect the upper cervical spine in younger children. Understanding normal spinal development is key to accurate diagnosis and treatment of these unique pediatric injuries.
Area of Science:
- Pediatric Orthopedics
- Spinal Surgery
- Pediatric Traumatology
Background:
- Spinal injuries are uncommon in children, representing a small percentage of all fractures and spinal lesions.
- Younger children are more susceptible to upper cervical spine injuries, accounting for 50% of all cervical spine (C-spine) injuries in this age group.
- Key differences in pediatric versus adult spines diminish around age 10, after which diagnostic and treatment principles largely align with adult care.
Purpose of the Study:
- To highlight the unique aspects of pediatric spinal injuries, particularly in the cervical spine.
- To discuss diagnostic challenges, including differentiating normal developmental variations from true injuries.
- To present classification and treatment strategies for specific pediatric spinal lesions like atlantooccipital and atlantoaxial dislocations.
Main Methods:
- Review of pediatric spinal injury cases, focusing on upper cervical spine lesions.
- Analysis of diagnostic imaging to identify common misinterpretations.
- Evaluation of treatment outcomes for specific injuries, including conservative (halo-vest) and operative interventions (internal fixation).
Main Results:
- Atlantooccipital dislocations (AOD) are common in children, with a proposed classification based on dislocation direction.
- Injuries to the synchondrosis of the dens, often resulting from motor vehicle accidents, require specific management, with both conservative and surgical options yielding success.
- Atlantoaxial dislocations (AAD) include translatory and rotatory instabilities, managed with fusion or halo-fixation, with delayed reductions also possible.
Conclusions:
- Accurate interpretation of pediatric spine X-rays, considering normal development, is crucial for correct diagnosis.
- Specific pediatric spinal injuries like AOD and synchondrosis fractures require tailored diagnostic and treatment approaches.
- Both conservative and surgical interventions can be effective for pediatric cervical spine injuries, with treatment selection based on injury severity and stability.
Abstract:
Injuries of the spine in children rarely occur. They amount to about 0.2% of all fractures and dislocation and to 1.5 to 3% of all lesions of the spine. The younger an injured child is, the more likely it has sustained a lesion of the upper cervical spine. This spinal segment in comparison to adults is concerned more often and accounts for 50% of all C-spine injuries. Important differences between the adult spine and the spine in the child disappear with the age of 10 years. Later diagnostics, classification and treatment correspond widely with the principles valid in adults. The knowledge of the normal shape and development of the spine are crucial in avoiding misinterpretations of X-ray films. Typical examples include the confusion of synchondrosis with fractures or of subluxations of the atlas and the C2/C3 segment with "true" instabilities. Relevant lesions always are accompanied by clear clinical symptoms. Specific injuries of the growing axial skeleton are lesions of the cartilaginous endplates and "fractures" of the synchondrosis. Atlantooccipital dislocations (AOD) occur typically in children. According to our experiences with 16 AOD we propose--dependent on the direction of dislocation of the occipital condyles--a simplified classification in anterior, posterior and completely unstable AOD. In one boy in our series we treated the lesion successfully by temporary internal fixation. He presented a massive improvement of initially subtotal neurologic symptoms. Injuries to the synchondrosis of the dens represent another typical lesion in childhood. Four out of 5 children treated in our clinic were involved as back seat passengers in head-on motor vehicle accidents. Three of them were restrained by 4 point children's seat harnesses. For conservative treatment we prefer a halo and plaster-vest for 12 weeks after closed reduction. We recommend operative treatment in cases of major dislocation with greater instability where it may be impossible to maintain alignment with halo fixation. Surgical equipment and techniques correspond in detail to those used in adults. Three of the five children mentioned have been stabilized successfully by anterior screw fixation. Atlantoaxial dislocations (AAD) are divided into translatory and rotatory instabilities. Sagittal dislocations of the atlas in children also need to be fixed by a fusion between C1 and C2. Rotatory instabilities in the acute phase are easy to reduce and are treated with a halo-fixator. According to our experiences in two delayed cases anatomical reduction is also possible after months partly by open, partly by closed means. For the lower C-spine lesion with encroachment of the spinal canal and above all ligamentous injuries represent a clear indication for operative treatment because, similar to the adult spine, they do not become stable after close management.